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. . . .. �....T�..: _..5. ..•y��..' �. . . <br /> WELL OR BORING LOCA710N MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 4 8 0 3 <br /> �` WELL AND BORING SEALING RECORD Menn�e9oNa Unique No. <br /> . County Name <br /> HLIIA�QiA Minnesota Statutes,Chapter f031 or W-series No. <br /> (Leave Dlank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-►Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 217 `l3 9 ,, ,, , b/13/9'7 � <br /> Numerical Street Address or Fire Number and Ciry of Well or Boring Location <br /> 3 315 North �ii�r�l Drive Depth Before Sealing 61 ft Original Depth 81 fl. <br /> Show exact location of well or boring � Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". f� location, showing property ��ngle Aquifer ❑ Multiaquifer <br /> �' lines,roads,and buildings. RECG'•�� <br /> N WELUBOR�NG �Aeasured ❑ Estimated <br /> `�—'^�---s..P.— <br /> ' OQNater Supply Well ❑Monit.Well <br /> - - - - -i-- -- -- ,-.._.. � ��.�1. . . �.O '7 <br /> ❑ Env.Bore Hole ❑Other ft. �]below ❑ a an ur{�ce1g9 j <br /> __f_ _l__ _l__ __l__ <br /> W E � CASING TYPE(S) - <br /> � <br /> i � <br /> � � � � � ❑ � ❑ IY �F l)��.�i�� <br /> --�- -�-- --�-- --�-- Steel Plastic Tile Other �' <br /> W mile <br /> --�- -�-- -�-- --�-- � X CASING . <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? � <br /> �L� S �J� ,.._—' <br /> r mi�e--q„ _...---..._.__._.�_.._.._...._..,... 2 in.from Q to 77 ft. ❑Yes �]No ❑ Ves ❑No ❑ Unknown <br /> I � <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> . Wa�ber <br /> Property owner's mailing address if ditterent than wall location address indicated above. in.from to . ft. ❑ Yes ❑No ❑ YeS ❑No ❑Unknown <br /> 3135 North Shore Drive SCREEWOPENHOLE <br /> Urono, MN 55391 <br /> Screen from 7? to g'1 ft. Open Hole from to fl. <br /> 09STRUCTIO WDEBRIS/FILL � <br /> WELL OWNER'S NAME �] Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owners mailing address if diHerent than property owner's adtlress indicated abova Type of ObslructioNDebns/Fill �u�p � <br /> ObslructioNDebris/Fill removad? [�Yes ❑ No <br /> PUMP <br /> Type 8he3110id i�TElI <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other - <br /> FORMATION <br /> If not known,indicate estimated tormation log from nearby well o�bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � <br /> d r i.f t � $� � No Annular Space Ezits <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ Casing PeAoration/Removal <br /> in.trom to R. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) <br /> GroutingMaterial ���tic3�d from 8� to � ft. yards L bags <br /> from to R. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags : <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes CS No � <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accrordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> R.�S. �tell Drilling '17276 <br /> - Contractor Business Name License or Re istratlon�° <br /> ��;� �'. _ � ----._ ! 1 I _/ J1 <br /> Authonzed Representative SignafurA e�e <br /> Jam�s Lea <br /> LOCALCOPY <br /> H 12 4 8 0 3 Name ol Person Sealing Well or Boring <br /> HE-01434-02 10/95R <br />